Helping Beneficiaries Understand Medicaid Managed Long ...The following dual eligible beneficiaries...

Helping Beneficiaries

Understand Medicaid Managed

Long Term Care (MLTC) Plans

© 2015 Medicare Rights Center

Medicare Rights Center

The Medicare Rights Center is a national,

nonprofit consumer service organization that

works to ensure access to affordable health

care for older adults and people with

disabilities through:

Counseling and advocacy

Educational programs

Public policy initiatives


Duals Coalition

The Coalition to Protect the Rights of New York’s

Dually Eligible (CPRNYDE): established in 2012 to

advocate beneficiary-focused implementation of

new managed care programs in New York State

Monthly meetings

Monthly e-newsletter

Beneficiary Engagement Workgroup

For more information: www.nyduals.org

Duals coalition education and advocacy is made

possible by the Altman foundation, Community

Catalyst and New York Community Project

Management Trust

http://www.nyduals.org/


What we will learn

You will come away from this training able to

help your clients understand

MLTC eligibility rules and notable exceptions

MLTC enrollment timeline in New York

MLTC coverage basics

How to make the right enrollment choices

MLTC marketing fraud and how to avoid it


MLTC Background


What is Medicare?

Federal program that gives health insurance to

people 65 and older and people under 65 who

have a disability

No income qualifications

Not affected by MLTC-only plans

Two ways to receive Medicare benefits:

Original Medicare

• Traditional program offered directly through the federal government

Medicare Advantage Plan

• Receive same Medicare benefits, but through a private plan


What is Medicaid? State and federal program offering health insurance to those with

limited incomes/assets

Available to people of most ages who meet financial limits

Each state has its own Medicaid rules

2014 New York Medicaid Qualification Limits

For 65+ or Disabled

Family Size Monthly Income

Limit

Asset Limit

Single $829 $14,550

Married $1,212 $21,450

Note: Different income limits apply for young and non-disabled adults.

Asset testing only applies to disabled or blind 21-64 year olds and

people who are 65+.


Medicare and Medicaid coordination

People who have both Medicare and Medicaid

are known as dual eligibles

Medicare always pays first

Medicaid is the payer of last resort

This means Medicaid always pays last after all other

forms of insurance have paid

Dual eligibles must have Medicare prescription

drug coverage (Part D)

Are automatically enrolled into Extra Help (aka Low-

Income Subsidy or LIS) to help with drug costs


Terms to know Long term care

Ongoing care needed to help perform everyday activities

Medicaid covers most long term care needs

Managed care

A plan operated by a private insurance company, intended

to better coordinate client’s health care

People in managed care plans usually must:

Use a certain group of doctors (in-network)

Get their plan’s permission before getting expensive care

Activities of Daily Living (ADLs)

Daily self care activities such as bathing, dressing, and

using the bathroom


The ACA and dual eligibles

The Affordable Care Act (ACA: Obamacare,

health reform): makes it easier for Medicare and

Medicaid to work together to provide health care

Two new programs in New York, both run by

private managed care plans:

MLTC: for managing an individual’s Medicaid long

term care (already launched)

FIDA: for managing an individual’s Medicaid AND

Medicare coverage and care (launching January 2015

in New York City and Nassau)


MLTC and FIDA: What’s the difference?

• Only covers Medicaid long term care, dental, vision, hearing, and podiatric services

• Does not affect Medicare coverage

• Is mandatory

MLTC

• Covers all health care services and items, including prescription drugs

• Provides both Medicare and Medicaid benefits

• Is optional

FIDA


MLTC Eligibility


Four MLTC eligibility criteria

To be eligible for mandatory MLTC, a beneficiary must

1) Be dually eligible Have both Medicare and Medicaid

2) Be at least 21 years old Beneficiaries under 21 may enroll if they are 18

or older and need certain types of care.

Enrollment for 18-21 year olds is not mandatory.

3) Receives 120+ days of

community-based long

term care

Long term care = Ongoing care one needs to

help perform everyday activities. Can include

care in the community or in a facility.

Examples include but are not limited to:

•Home health care

•Nursing home care

•Medical adult day health care

4) Live in a county in New

York State where MLTC

has been rolled out

All New York State counties will have rolled out

MLTC by March 2015 (see next slide)

Beneficiaries must meet all four eligibility criteria to qualify for mandatory MLTC in NY


MLTC rollout in New York State

King

New York

Bronx

Queens

Clinton

Essex

St. Lawrence

Hamilton Warren

Washington

Rensselaer

Columbia

Dutchess

Westchester

Suffolk

Nassau

Richmon

d

Rockland

Orange

Sullivan

Ulster

Delaware Greene

Albany

Otsego Schoharie

Montgomery

Saratoga

Schenectady

Broome

Chenango

Cortland

Madison

Oneida

Herkimer

Fulton

Cattaraugus Allegany Steuben

Chemung Tioga

Schuyler Tompkins

Onondaga

Cayuga Erie

Wyoming Livingsto

n Yates

Ontario

Genesse

Niagara

Orleans Monroe Wayne

Seneca

Oswego

Jefferson

Lewis

Chautauqua

Franklin


Mandatory MLTC exclusions The following dual eligible beneficiaries are excluded from

mandatory MLTC, even if they meet the four criteria: Native Americans

Beneficiaries who are under 18

• Beneficiaries 18-21 are not mandated to enroll, but may elect to enroll

Beneficiaries who only receive Social Adult Day Care services

• As opposed to Social and Medical Adult Day Care services

Beneficiaries who only need housekeeping services

• Do not need help with any other ADLs

Beneficiaries who have Traumatic Brain Injury (TBI) waivers

Beneficiaries who have Nursing Home Transition & Diversion (NHTDW)

waivers

Beneficiaries who have Office for People with Developmental Disabilities

(OPWDD) waivers

Beneficiaries who are currently receiving hospice care

Beneficiaries who live in an Assisted Living Program


MLTC Enrollment


Remember

Enrollment into MLTC for beneficiaries who

meet the four criteria is mandatory

Enrollment into MLTC for beneficiaries who are 18-

21 years old and meet the other three criteria is

optional

The four criteria are

Dually eligible

21 or over

Need 120+ days of community-based long term care

Live in a New York State county where MLTC has

been adopted


Medicaid enrollment

All beneficiaries continue to apply for Medicaid via their county

Department of Social Services (DSS, or the Human

Resources Administration (HRA) in NYC)

Once Medicaid application is approved, if the beneficiary

meets all four MLTC criteria: referred to New York Medicaid

Choice

Beneficiaries no longer apply for long term care services

coverage (like home care) through DSS/HRA

Enrollment into MLTC serves as long term care benefits application

Must recertify for Medicaid every year to retain MLTC eligibility

Beneficiaries with Medicaid spend-down may have trouble

enrolling into an MLTC plan

Contact DSS/HRA


MLTC enrollee groups

1) Beneficiaries who meet all four criteria when their county implements

MLTC:

Eligibility not assessed; county knows they are eligible

Receive Announcement Letter from NY Medicaid Choice the month their

county rolls out

Receive Choice Notice from NY Medicaid Choice

2) Beneficiaries who become eligible for all four criteria after their county

implements MLTC:

MLTC eligibility assessment performed by Conflict-Free Evaluation and

Enrollment Center (CFEEC)

Facility refers client to NY Medicaid Choice

New York Medicaid Choice sends Choice Notice

All four criteria

County rollout Announcement

Letter

Choice

Notice

County rollout

All four criteria

Eligibility assessment

Referral to NY Medicaid

Choice

Choice

Notice


More about MLTC notices

1) Beneficiaries who meet all four criteria when their county

implements MLTC receive an Announcement Letter

from NY Medicaid Choice the month of implementation

Two weeks later, beneficiary receives a Choice Notice

from NY Medicaid Choice with a brochure of MLTC plan

options in their area

This notice gives 60 days to choose a plan

If plan is not chosen, beneficiary is automatically

assigned to a plan 60 days after receiving Choice Notice

Plan may or may not have beneficiary’s providers in the

network

Not locked into auto-assignment; can change plans up to

once per month


More about MLTC notices 2) Beneficiaries whose long term care facility contacts New

York Medicaid Choice because they become eligible for

MLTC receive the Choice Notice with a brochure of

MLTC plan options in their area

This notice gives 60 days to choose a plan

If plan is not chosen, beneficiary is automatically

assigned to a plan 60 days after receiving Choice Notice

Plan may or may not have beneficiary’s providers in the

network

Not locked into auto-assignment; can change plans up to

once per month


MLTC notices Beneficiaries who already meet the four criteria when

their county implements MLTC will receive an

Announcement Letter when their county joins rollout

Two weeks later, beneficiary receives a Choice Notice

with a list of MLTC plans available in their area

This notice gives 60 days to chose a plan


Contact for MLTC enrollment

Once a plan is selected from the brochure, beneficiary

(or caregiver) should contact New York Medicaid

Choice to enroll

Write down the name of representative, date, and

outcome of the call

Beneficiaries are not locked into their plan choice; can

change plans up to once per month

New York Medicaid Choice

Also known as Maximus

1-888-401-6582

http://www.nymedicaidchoice.com/




MLTC Coverage Basics


MLTC coverage Home care

Help with ADLs

Skilled nursing

Physical, occupational, speech therapy

Adult day health care

Medical only, or Medical and Social together

Home-delivered meals, congregate meals

Medical equipment, eyeglasses, hearing aides, home

modifications

Non-emergency medical transportation

Podiatry, audiology, dentistry, optometry

Nursing home care


Care needs assessment

MLTC plans must conduct a assessment of the

beneficiary’s care needs after the plan is selected and

before the person is enrolled

This is different from the CFEEC eligibility assessment

Care needs assessment must take plan within 30 days

after the plan is contacted

A nurse will come to the beneficiary’s home to determine

care needs (e.g., if the client needs home care, nursing

home care, adult day care)

Beneficiaries may contact multiple plans for assessments

A care assessment must also happen every six

months or sooner if there is a significant change in

condition


Continuation of care protection

Each new MLTC plan member continues to

receive services under their old plan of care for

at least 90 days after new plan takes effect, or

until a new plan of care is completed by their

provider

Whichever is later

Even if old care plan takes place out of network

MLTC plan must send new written plan of care to

beneficiary

Beneficiary can appeal new plan of care if necessary


CDPAP

Consumer Directed Personal Assistance

Program (CDPAP) – beneficiary coordinates

their care and who they receive it from

To use with MLTC, beneficiary must request

through plan

Can appoint representative if unable to own

coordinate care

Can appeal if plan denies request to participate

in CDPAP


MLTC Choices


MLTC plan choices

A beneficiary who meets all four eligibility

criteria can make one of three MLTC choices

MLTC-only coverage

Medicaid Advantage Plus (MAP)

Program of All-Inclusive Care for the Elderly (PACE)


MLTC Medicaid Managed Long Term Care (MLTC)

Known as a partially capitated plan, only covers a small portion of

Medicaid services

Home care

Adult day health care

Home-delivered meals, congregate meals

Medical equipment, eyeglasses, hearing aides, home modifications

Non-emergency medical transportation

Podiatry, audiology, dentistry, optometry

Nursing home care

Medicare and acute care Medicaid not affected

Acute care Medicaid = hospital inpatient and outpatient care, pays after

Medicare

Between three and five insurance cards


MLTC Medicaid MLTC with

Original Medicare

Medigap Plan C J Doe

Member ID:

123456ABC

Managed Long Term

Care Plan Card MLTC Plan J Doe

Member ID:

123456ABC

Medicaid MLTC with

Medicare Advantage

Managed Long Term

Care Plan Card MLTC Plan J Doe

Member ID:

123456ABC

Medicare Advantage Plan Benefit Card Elder Plus Gold Member Plan J Doe

Member ID: 123456ABC

Original Medicare Card Part D Card

Medicaid Card MLTC Plan Card

(Maybe) Medigap Card

Medicaid Card

Medicare Advantage Plan Card

MLTC Plan Card


MAP

Medicaid Advantage

Plus (MAP)

Known as a fully

capitated plan, plan

covers all Medicare and

Medicaid services

One plan card

Very similar to FIDA

Is being phased out in

favor of FIDA

Medicaid Advantage Plus Plan Card Medicaid Advantage Plus J Marks

Member ID:

123456ABC


PACE

Program of All-Inclusive Care for

the Elderly (PACE)

Known as a fully capitated

plan, plan covers all Medicare

and Medicaid services

One plan card

Provides Medicare and Medicaid

services from one facility or site to

ensure better care coordination

Must be at least 55 years old and

live in an area serviced by a PACE

program

PACE Plan Card PACE Card J Smith

Member ID:

123456ABC


How to choose a plan

MLTC: Make sure long term care, hearing,

dental, podiatry, and vision providers are in the

MLTC plan’s network

MAP: Make sure all of providers are in network

Includes primary care, long term care, specialists,

etc.

Also have to make sure prescription drugs are on

the list of covered drugs (formulary) and that

pharmacies are in network

PACE: Must use only PACE facility providers

and pharmacies


MLTC plan marketing rules Marketing = written or oral communication used to encourage enrollment into a plan

Allowed Not allowed

Only New York State Department of

Health-Approved marketing materials

Cold calling beneficiaries or coming to

their homes uninvited

Providing any potential enrollee not

referred by New York Medicaid Choice

with information describing managed long

term care, a list of available Plans and

information on how to reach New York

Medicaid Choice

Marketing in hospital emergency rooms,

treatment rooms, patient rooms, medical

professional offices, Nursing Home or

Adult Care Facility resident rooms, Adult

Day Health Care Programs and Social

Day Care sites

Making reference in marketing materials

and activities only to benefits/services

offered by the plan

Providers are not allowed to market plans

to beneficiaries at any time for any reason

Plan marketing activities at medical

facilities with provider permission and

prominent display of all other MLTC plans

operating in the county or borough

Offer benefits, services, or gifts valued at

more than $5.00 to persuade people to

enroll with such gifts being offered

regardless of beneficiary’s intent to enroll.


Common MLTC challenges

Can be difficult to determine if client has MLTC

MLTC is not shown on card

Notices will show MLTC

Ask what types of services beneficiary receives

Can be difficult to enroll client in MLTC with spend-down

Contact DSS/HRA or MLTC plan expert staffer

Your client may need more services

Work with case manager, may have to appeal


Conclusion

If your client is a dual eligible and receives 4 or more

months of long term care, they must get long term care

from a managed care plan

Currently, they probably already get long term care

benefits from an MLTC plan

Going forward, they may also qualify for a FIDA plan

FIDA plans provide all Medicare and Medicaid

benefits

If your client does nothing, they will be automatically

enrolled in a FIDA plan


Where to find information

New York Medicaid Choice

888-401-6582


Can contact to enroll in or switch FIDA or MLTC

plans

Independent Consumer Advocacy Network

(ICAN)

844-614-8800

http://www.icannys.org

Can contact with any problems or concerns about

MLTC or FIDA



http://www.icannys.org/

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